Panton-Valentine leukocidin-positive Staphylococcus aureus osteomyelitis of the tibia in a 10-year-old child

Abstract

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is increasing in prevalence among asymptomatic carriers and in cases of paediatric soft-tissue infections alike. CA-MRSA may express virulence factors such as Panton-Valentine leukocidin, which makes soft-tissue and hard-tissue infections due to such organisms challenging to treat. We report a case of osteomyelitis of the proximal tibia in a 10-year-old boy and discuss its management in what is to the authors' knowledge the first case report of Panton-Valentine leukocidin-positive CA-MRSA osteomyelitis in a child in the UK.

Update on the Management of Pediatric Acute Osteomyelitis and Septic Arthritis

“…In recent years, acute osteoarticular infections due to S. aureus strains producing Panton-Valentine leukocidin have been reported, although not so frequently in Europe [ 29 , 30 , 31 , 32 , 33 ]. Panton-Valentine leukocidin (PVL) is a toxin that causes tissue necrosis and destruction of the neutrophils, thereby facilitating the extension of the infection, and children affected by this pathogen have more aggressive clinical features [ 21 , 22 , 30 , 34 , 35 , 36 ].…”

“…The risk of complications such as subperiosteal abscesses, pyomyositis, necrotizing fasciitis, and orthopedic sequelae is high [ 37 ]. Therefore, cases of bone or joint infection caused by S. aureus strains producing PVL require more aggressive and prolonged antimicrobial treatment and often require repeated surgical debridement [ 32 , 38 ]. The use of fluoxacillin, clindamycin or linezolid is recommended in these cases, with daptomycin considered as a second-line antibiotic.…”

Pediatric Methicillin-Resistant Staphylococcus aureus Osteoarticular Infections

“…Disseminated MRSA infections with sepsis can have high mortality. Several reports have shown that patients with OSI due to PVL-carrying S. aureus strains have a greater risk of developing pyomyositis, necrotizing fasciitis, and orthopedic sequelae, thus requiring more aggressive management with prolonged antimicrobials and multiple surgical debridement procedures [ 25 , 26 , 27 , 28 ]. Serious orthopedic complications in children include growth plate damage, limb shortening and limb length discrepancy, angular limb deformity, femoral head AVN (avascular necrosis), joint stiffness, and osteonecrosis [ 26 ].…”

Management of Pediatric Acute Hematogenous Osteomyelitis, Part II: A Focus on Methicillin‐Resistant Staphylococcus aureus, Current and Emerging Therapies

“…The transition can be made by following key indicators such as clinical improvement and a 50% reduction in C‐reactive protein . When transitioning to oral therapy and determining the total duration of treatment, it is important to keep in mind the presence of PVL‐positive isolates and other toxins produced by MRSA that can lead to subsequent sequelae and require longer durations of therapy . Therefore, duration should generally be a minimum of 4 weeks but should be tailored based on patient response, disease course, and the development of any adverse effects or complications.…”

“…Further, CA‐MRSA is more likely to cause severe disease due to the higher likelihood of producing Panton‐Valentine leukocidin (PVL), in addition to several other toxins associated with S. aureus including enterotoxin B and phenol‐soluble modulins . Complications of toxin production include abscess development, deep vein thrombosis, and sepsis …”